Healthcare Provider Details

I. General information

NPI: 1528837580
Provider Name (Legal Business Name): CUP OF TEA PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 01/01/2024
Certification Date: 12/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2846 S PINE AVE
MILWAUKEE WI
53207-2221
US

IV. Provider business mailing address

2846 S PINE AVE
MILWAUKEE WI
53207-2221
US

V. Phone/Fax

Practice location:
  • Phone: 872-222-9246
  • Fax:
Mailing address:
  • Phone: 872-222-9246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DAN WOLFF
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 920-229-9978